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STATE OF CONNECTICUT INSURANCE DEPARTMENT
BULLETIN HC-97-14-2 JUNE 26,2014
TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE SMALL GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT
RE: REVISED STATUTORY PLANS REQUIRED BY CONN. GEN. STAT. §38a-568
Conn. Gen. Stat. §38a-568 requires health insurance carriers, including health care centers that transact small employer group health insurance business in this state, to offer plans established by the Board of the Connecticut Small Emplo yer Health Reinsurance Pool (CSEHRP). The CSEHRP Board filed revised major medical and health care center plans that were approved by the Insurance Department on May 30, 2014. The HMO version of the statutory plan must be revised to be in compliance with Regulations of Connecticut State Agencies §38a- l 92 et. seq. This regulation sets a minimum $1500 deductible for health care centers. Increasing the $1000 deductible to $1500 for the HMO version of the statutory plan produces an actuarial value of 80.2%, so remains within the required range for a gold plan.
This bulletin rescinds Bulletin HC-97 that was issued on June 9, 2014. The revised approved schedules of benefits are attached as Exhibits I and II. The statutory plan for indemnity plans remains unchanged. A copy of the output from the actuarial value calculator is also attached as Exhibit III. Carriers must include the appropriate version of the revised plans as part of their small employer form and rate filings for January 1,2015.
Questions
Please contact the Insurance Department Life and Health Division at [email protected] with any que tions .
Anne Melissa Dowling Deputy Insurance Commissioner
www.ct.gov/cid P.O. Box 816 • Hartford. cr 06142-0816
An Equal Opportunity Employer
EXHIBIT I
CSEHRP
Indemnity Gold Plan
Plan Overview In-Network Out-of-Network Member Pays Member Pays
Medical Deductible $1,000Individual $3,000
Family $2,000 $6,000 (copavs are not applied 10 deductible}
Prescription Drug Deductible $0Individual $350
Family $0 $700 (copays are not applied to deductible)
Out-of-Pocket Maximum Individual $3,000 $6,000
$6,000Family $12,000
Physiciau Oflic e Visits
Preventive Care/Screenings/Immunizations $0 30% coinsurance
Primary Care (injury or illness) $20 copay 30% coinsurance**
Specialist $45 copay 30% coinsurance**
Emeraencv/Uraent Care
Urgent Care Center or Facility $75 copay 30% coinsurance**
Emergency Room $150 copay $150 copay
Ambu lance $0 $0
Hospital Services
Inpatient $500 copay per day to a max imum of 30% coinsurance** $1,000 per admission"
Outpatient (performed at hospital or $500 copay* 30% coinsurance** ambulatory facilit y)
Skilled Nursing Facility $500 copay per day to a maximum of 30% coinsurance** 90 day calendar year maximum $1.000 per admission*
Mental Health. Substa nce Abuse & Behavioral Health Care
Mental Health. Substance Abuse & Covered same as any other illness Covered same as an y Behavioral Health Services other illness
Hospice Ca re
Hospice Services I $0 I 30% coinsurance**
Outpatien t Services
Home Health Care 25% coinsurance 100 visit calendar year maximum $0 subject to
a $50 deductible
$75 copay per service up to a combined
Advanced Radiology (CTIPET Scan. MRI) calendar year maximum of$375 for MRI and
CT scans; 30% coinsurance* *
$400 for PET scans
*After in-network medical deductible is met **After out-of-network deductible is met
n it G0 Id PIanI demruty Plan 0 erview In-Network Out-of-Network
Member Pays Member Pays Outpatient Services
Non-Advanced Radiology (X-ray, $45 copay 30% coinsurance** Diagnostic)
Laboratory Services $30 copay 30% coinsurance**
Rehabilitative & Habilitative Therapy $30 copay 30% coinsurance** (Physical, Speech, Occupational) combined 40 visit calendar year maximum
Chiropractic Care $45 copay 30% coinsurance** 20 visit calendar maximum
Other Services
Durable Medical Equipment 30% coinsurance 30% coinsurance**
Prosthetics 30% coinsurance 30% coinsurance**
Diabetic Supplies & Equipment 30% coinsurance 30% coinsuran ce**
Prescription Drugs
Generic Drugs $5 cooav 30% coinsurance** **
Preferred Brand Drugs $25 copay 30% coinsurance****
Non-Preferred Brand Drugs $50 copay 30% coinsurance****
Specialty Drugs $60 couav 30% coinsurance****
P di my (f hOldI.' iatric-'0 I Services or c I ren un d er age 19)
Pediatric Dental Car e
Diagnostic & Preventive $0 50% coinsurance** (Oral Exam, Cleaning, X-ray)
Basic Restorative 20% coinsurance 50% coinsurance** (Filling, Simple Extraction)
Major Restorative 40% coinsurance 50% coinsurance** (Endodontic, Crown)
Orthodontia Services 50% coinsurance 50% coinsurance** medically necessary only
Pediatric Vision Car e
Routine Eye Exam $45 copay 30% coinsurance
Prescription Eye Glasses lenses: $0 100% coinsurance one pair offrames & lenses per calendar collection frames: $0 year non-collection frames: Members choosing to
upgrade from a collection frame to a non-collection frame will be given a credit equal to
the cost of the collection frame and will be entitled to a negotiated discount
*After in-network medical deductible is met
**After out-of-network medical deductible is met
***After in-network prescription drug deductible is met
****After out-of-network prescription drug deductible is met.
EXHIBIT II
CSEHRP
HMO Gold Plan
Plan 0 erview In-Network
Medical Deductible
Member Pays
Individual $1,500 Family $3,000 (copays are not applied to deductible)
Prescription Drug Deductible Individual $0 Family $0 (copays are not applied to deductible)
Out-of-Pocket Maximum Individual $3,000 Family $6,000
Physician Office Visits
Preventive Care/Screenings/Immunizations $0
Primary Care (injury or illness) $20 copay
Specialist $45 copay
Emeraencv/Urzent Care
Urgent Care Center or Facility $75 copay
Emergency Room $150 copav
Ambulance $0
Hospital Services
Inpatient $500 copay per day to a maximum of$1,000 per admission"
Outpatient (performed at hospital or $500 copay* ambulatory facility)
Skilled Nursing Facility $500 copay per day to a maximum of$1,OOO per admission* 90 day calendar year maximum
Mental Health, Substance Abuse & Behavioral Health Care
Mental Health, Substance Abuse & Covered same as any other illness Behavioral Health Services
Hosnice Care
Hospice Services $0
Outpatient Services
Home Health Care SO 100 visit calendar year maximum
$75 copay per service up to a combined calendar year Advanced Radiology (CTIPET Scan, MRI) maximum of $375 for MRI and CT scans;
$400 for PET scans
*After in-network medical deductible is met
HMO Gold Plan Plan Overview In-Netwo rk
Member Pays Outpatient Services
Non-Advanced Radiology (X-ray, Diagnostic)
$45 copay
Laboratory Services $30 cona y
Rehabilitative & Habilitative Therapy (Physical, Speech, Occupational) combined 40 visit calendar year maximum
$30 copay
Chiropractic Care 20 visit calendar maximum
$45 copay
Other Services
Durable Medical Equipment 30% coinsurance
Prosthetics 30% coinsurance
Diabetic Supplies & Equipment 30% coinsurance
Prescription Drugs
Generic Drugs $5 copay
Preferred Brand Drugs $25 copay
Non-Preferred Brand Drugs $50 conav
Specialty Drugs $60 copay
Pediatric-Only Services (for children under age 19)
Pediatric Dental Cure
Diagnostic & Preventive (Oral Exam, Cleaning, X-ray)
$0
Basic Restorative (Filling, Simple Extraction)
$45 copay
Major Restorative (Endodontic, Crown)
$45 copay
Orthodontia Services medicallv necessary onlv
$45 copay
Pediatric Vision Care
Routine Eve Exam $45 copav
Prescription Eye Glasses one pair offrames & lenses per calendar year
lenses: $0 collection frames: $0
non-collection frames: Members choosing to upgrade from a collection frame to a non-collection frame will be given a credit equal to the cost of the collection frame and will be
entitled to a negotiated discount
*After in-network medical deductible is met
User Inputs for Plan Parameters
Use Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day?
Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?
Indicate if Plan Meets CSR Standard?
Desired Metal Tier,....,...!:L-======-'
Deductible ($)
Coinsurance (%, Insurer's Cost Share)
OOP Maximum ($)
OOP Maximum if Separate ($)
HSA/HRA Options
HSA/HRA Employer Contribution? D
---" Tier 1 Plan Benefit Design
I Combined
Tier 1 Click Here for Important Instructions trI
Subject to Copay, if Type of Benefit
Deductible? seoarate I~ f-'.
Medical I DAII r-r ~ ~~ .......... :=-'JI
Emergency Room Services D $150.00 la All Inpatient Hospital Services (inc. MHSA) o $500.00
Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) D $20.00
Specialist Visit D D -
$45.00
Mental/Behavioral Health and Substance Abuse Disorder Outpatient D D $58 .00
Services -
Imaging (CT/PETScans, MRls) D D $75.00 Rehabilitative Speech The rapy o D
D D Rehabil itative Occupational and Rehabilitative Physical Therapy
Preventive Care/Screening/Immunization I Laboratory Outpatient and Professional Services o D X-rays and Diagnostic Imaging D D
$30.00
$30.00
$30.00
$45.00
Skilled Nursi ~g Facility • o D $500.00 .
~I !!!!!!!!!!!!!!!!
Drug
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Drugs
Generics
Preferred Brand Drugs
Non-Preferred Brand Drugs- - -'='--- ----
Specialty Drugs (i.e . high-cost)
D - -D
-
o All
0 0 D D
-
D
D o All
D D 0 D
$5.00
$25.00
$50.00
$60.00
- 1
Output
Status/Error Messages: Calculation Successful.
Actuarial Value: 80 .2%
Metal Tier: Gold
Options for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?
Specialty Rx Coinsurance Maximum: D
Set a Maximum Number of Days for Charging an IP Capay?
# Days (1-10) : D
2
Begin Primary Care Cost-Sharing After a Set Number of Visits?
# Visits (1-10): D
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):
D